guidelines for pediatric dentistry
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GUIDELINES FOR
PEDIATRIC DENTISTRY
Version 1
النسخة الإلكترونية هي النسخة المضبوطة وفق إجراء ضبط الوثائق۔ النسخ الورقية غير
مضبوطة وتقع على مسؤولية حاملها۔
Electronic copy is controlled under document control procedure.
Hard copy is uncontrolled & under responsibility of beholder.
يسمح بالوصول وبالاحتفاظ بهذه الوثيقة مع مصدرها أو مع المسؤول عن تطبيقها أو مع
المطبق عليهم۔
It is allowed ONLY to access and keep this document with who
issued, who is responsible and to whom it is applicable.
:تصنيف امن المعلومات بيانات مفتوحة شارك–
سري
حساس–مشارك سري–مشارك
Information security code: Open Shared -
Confidential
Shared-Sensitive Shared-Secret
Health Policies and Standards Department
Health Regulation Sector (2021)
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INTRODUCTION
Dubai Health Authority (DHA) is the responsible entity for regulating, licensing and
monitoring health facilities and healthcare professionals in the Emirate of Dubai. The
Health Regulation Sector (HRS) is an integral part of DHA and was founded to fulfil the
following overarching strategic objectives and program:
Objective #1: Position Dubai as a global medical destination by introducing a value-based,
comprehensive, integrated and high quality service delivery system.
Objective #2: Direct resources to ensure healthy and safe environment for Dubai population.
Strategic Program #5: Oral & Dental Care- This program focuses on improving the oral
health outcomes and ensure that all individuals have access to high quality treatments and
effective prevention programs for dental care.
ACKNOWLEDGMENT
This document was developed by Dental Services Department, Primary Healthcare Services
Sector (PHCSS). It has further been reviewed by the Health Policy and Standards
Department (HPSD).
HRS would like to acknowledge and thank all parties that participated and worked toward
developing these guidelines to ensure improving the quality and safety of healthcare
services.
The Health Regulation Sector
Dubai Health Authority
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TABLE OF CONTENTS
INTRODUCTION............................................................................................................... 2
ACKNOWLEDGMENT ....................................................................................................... 2
EXECUTIVE SUMMARY .................................................................................................... 7
DEFINITIONS ................................................................................................................... 9
ABBREVIATIONS ........................................................................................................... 11
A. GUIDELINES FOR APPLICATION OF FLUORIDE VARNISH......................................... 13
1. BACKGROUND ....................................................................................................... 14
2. SCOPE ................................................................................................................... 14
3. PURPOSE ............................................................................................................... 14
4. APPLICABILITY ...................................................................................................... 14
5. RECOMMENDATION ONE: INDICATIONS ................................................................. 15
6. RECOMMENDATION TWO: ADVANTAGES ............................................................... 16
7. RECOMMENDATION THREE: APPLICATION TECHNIQUE .......................................... 16
8. RECOMMENDATION FOUR: SPECIAL CONSIDERATIONS ........................................... 17
B. GUIDELINES FOR APPLICATION OF SILVER DIAMINE FLUORIDE.............................. 18
1. BACKGROUND ....................................................................................................... 19
2. SCOPE ................................................................................................................... 20
3. PURPOSE ............................................................................................................... 20
4. APPLICABILITY ...................................................................................................... 21
5. RECOMMENDATION ONE: CLINICAL STEPS ............................................................. 21
6. RECOMMENDATION TWO: SPECIAL CONSIDERATIONS ............................................ 24
C. GUIDELINES FOR THE APPLICATION OF HALL TECHNIQUE ..................................... 26
1. BACKGROUND ....................................................................................................... 27
2. SCOPE ................................................................................................................... 28
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3. PURPOSE ............................................................................................................... 28
4. APPLICABILITY ...................................................................................................... 28
5. RECOMMENDATION ONE: CASE SELECTION............................................................ 29
6. RECOMMENDATION TWO: STEPS FOR FITTING A HALL CROWN .............................. 30
7. RECOMMENDATION THREE: SPECIAL CONSIDERATIONS ......................................... 31
D. GUIDELINES FOR THE USE OF LOCAL ANESTHESIA IN PEDIATRIC PATIENTS .......... 34
1. BACKGROUND ....................................................................................................... 35
2. SCOPE ................................................................................................................... 35
3. PURPOSE ............................................................................................................... 36
4. APPLICABILITY ...................................................................................................... 36
5. RECOMMENDATION ONE: TOPICAL ANESTHETICS ................................................. 36
6. RECOMMENDATION TWO: SELECTION OF SYRINGES AND NEEDLES ........................ 37
7. RECOMMENDATION THREE: INJECTABLE LOCAL ANESTHETIC (LA) AGENTS............ 37
8. RECOMMENDATION FOUR: DOCUMENTATION OF LOCAL ANESTHESIA ................... 39
9. RECOMMENDATION FIVE: LA COMPLICATIONS ...................................................... 39
10. RECOMMENDATION SIX: LOCAL ANASTHESIA WITH SEDATION, GENERAL
ANASTHESIA, AND/OR NITROUS OXIDE/OXYGEN ANALGESIA/ANXIOLYSIS ..................... 42
E. GUIDELINES FOR NITROUS OXIDE (N2O) INHALATION SEDATION .......................... 43
1. BACKGROUND ....................................................................................................... 44
2. SCOPE ................................................................................................................... 45
3. PURPOSE ............................................................................................................... 45
4. APPLICABILITY ...................................................................................................... 45
5. RECOMMENDATION ONE: SEDATION IN PEDIATRIC DENTISTRY .............................. 45
6. RECOMMENDATION TWO: TRAINING FOR N2O SEDATION ....................................... 45
7. RECOMMENDATION THREE: PATIENT SELECTION ................................................... 46
8. RECOMMENDATION FOUR: INDICATIONS ............................................................... 47
9. RECOMMENDATION FIVE: CONTRAINDICATION ...................................................... 48
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10. RECOMMENDATION SIX: PATIENT ASSESSMENT................................................. 49
11. RECOMMENDATION SEVEN: PATIENT INFORMATION .......................................... 49
12. RECOMMENDATION EIGHT: TECHNIQUES OF N2O/O2 SEDATION ......................... 53
13. RECOMMENDATION NINE: PATIENT MONITORING .............................................. 54
14. RECOMMENDATION TEN: ADVERSE EFFECTS OF N2O INHALATION ...................... 54
15. RECOMMENDATION ELEVEN: DISCHARGE CRITERIA ............................................ 54
16. RECOMMENDATION TWELVE: SAFETY OF STAFF ................................................ 55
17. RECOMMENDATION THIRTEEN: EQUIPMENT ...................................................... 56
F. GUIDELINES FOR COMPLETE ORAL REHABILITATION UNDER GENERAL
ANAESTHESIA............................................................................................................... 59
1. BACKGROUND ....................................................................................................... 60
2. SCOPE ................................................................................................................... 61
3. PURPOSE ............................................................................................................... 61
4. APPLICABILITY ...................................................................................................... 61
5. RECOMMENDATION ONE: BENEFITS COMPLETE ORAL REHABILITATION UNDER GA 61
6. RECOMMENDATION TWO: PATIENT SELECTION CRITERIA ...................................... 62
7. RECOMMENDATION THREE: PATIENT EXCLUSION CRITERIA ................................... 62
8. RECOMMENDATION FOUR: PRE-OPERATIVE ASSESSMENT (PROTOCOL OF REFERRAL)
62
9. RECOMMENDATION FIVE: PRE-OPERATIVE INVESTIGATIONS .................................. 63
10. RECOMMENDATION SIX: TREATMENT UNDER GA ............................................... 64
11. RECOMMENDATION SEVEN: DISCHARGE AND POST-OPERATIVE CARE ................ 66
G. GUIDELINES FOR MANAGEMENT OF EARLY CHILDHOOD CARIES ........................... 68
1. BACKGROUND ....................................................................................................... 69
2. SCOPE ................................................................................................................... 70
3. PURPOSE ............................................................................................................... 70
4. APPLICABILITY ...................................................................................................... 70
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5. RECOMMENDATION ONE: ETIOLOGY OF EARLY CHILDHOOD CARIES (ECC) .............. 70
6. RECOMMENDATION TWO: CLINICAL REPRESENTATION OF EARLY CHILDHOOD
CARIES .......................................................................................................................... 71
7. RECOMMENDATION THREE: CONSEQUENCES OF ECC ............................................. 72
8. RECOMMENDATION FOUR: MANAGEMENT OF ECC ................................................. 73
9. RECOMMENDATION FIVE: CARIES RISK ASSESSMENT ............................................. 73
10. RECOMMENDATION SIX: PERINATAL PERIOD AND ANTICIPATORY GUIDANCE ...... 74
11. RECOMMENDATION SEVEN: RECOMMENDATIONS FOR PERINATAL AND INFANT
ORAL HEALTH ............................................................................................................... 75
12. RECOMMENDATION EIGHT: CONCLUSION........................................................... 79
KEY PERFORMANCE INDICATORS (KPIs) ........................................................................ 81
REFERENCES ................................................................................................................. 86
APPENDICES:................................................................................................................. 95
APPENDIX 1: CLINICAL PATHWAY IN THE DECISION MAKING PROCESS FOR THE USE OF
N2O ADMINISTRATION ................................................................................................... 95
APPENDIX 2: CARIES- RISK ASSESSMENT FORM FOR 0-3 YEARS OLDS ............................. 96
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EXECUTIVE SUMMARY
Clinical guidelines to enhance the standard of care in health facilities are increasingly
becoming part of current practice and will become more common over the next decade.
These Clinical Guidelines aim to improve the quality and the level of healthcare provided to
the clients. Healthcare providers can use these guidelines to answer specific questions in
day-to-day practice and as an information source for continuing professional education.
This document presents a framework for Pediatric dentists to:
To present a framework to equip the Pediatric Dentist with the necessary information
and recommendations for the application of fluoride varnish in pediatric patients.
To assist dental healthcare providers when using Silver Diamine Fluoride (SDF) in the
Management of Dental Caries Lesions.
To provide an overview on the topic of “Hall technique” to assist Pediatric Dentist make
informed choices in dental management.
To assist dental healthcare providers using Local Anaesthesia (LA) to control pains in
infants, children, adolescents and people with determination during the delivery of oral
health care services.
To ensure pediatric patients are provided with effective and successful conscious
sedation with N2O if required, in clinical practice.
To provide quality dental care that is standardized, successful and efficient when
referring to and performing complete oral rehabilitation under General Anaesthesia
(GA) in children.
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To increase knowledge of oral disease prevention from infancy through adolescence to
help reduce the incidence of early childhood caries.
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DEFINITIONS
Clinical Privileging: is the process of giving a DHA licensed Healthcare Professional (HP)
permission to carry out specific duties as per health facility scope of practice and licensure.
This involves the review of credentials and qualifications, training, competence, practical
independence and experience.
Dental Caries: is the cavity formation in teeth caused by bacteria that attach to teeth and
form acids in the presence of sucrose, other sugars, and refined starches; tooth decay.
Dental Decay in Infants and Young Children is also called “nursing caries”, “nursing bottle
caries”, “nursing bottle syndrome”, baby bottle caries” and “baby bottle tooth decay”.
Dental Local anesthesia: is the temporary loss of sensation including pain in one part of
the body produced by a topically applied or injected agent without depressing the level of
consciousness.
Early Childhood Caries (ECC) is the presence of one or more decayed (non-cavitated or
cavitated lesions), missing (due to caries) or filled tooth surfaces” in any primary tooth in a
child 71 months of age or younger.
Fluoride Varnish: is a highly concentrated form of Fluoride, which is applied to the tooth's
surface.
Medical Director: is a DHA licensed physician who holds responsibility and oversight of
medical services and clinical operations within a DHA licensed health facility.
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Severe Early Childhood Caries (S-ECC) is the caries in children younger than 3 years of
age, any sign of smooth-surface caries is indicative of severe early childhood caries. From
ages three through five, one or more cavitated, missing (due to caries), or filled smooth
surfaces in primary maxillary anterior teeth or a decayed, missing, or filled surfaces with a
score of =4 (age three), =5 (age four), or =6 (age five) is indicative of S-ECC.
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ABBREVIATIONS
AAPD : American Academy of Pediatric Dentistry
ADA : American Dental Association
ASA : American Society of Anesthesiologists
BMI : Body Mass Index
CaF2 : Calcium Fluoride
CNS : Central Nervous System
CPC : Clinical Privileging Committee
COPD : Chronic Obstructive Pulmonary Disease
DHA : Dubai Health Authority
DHIC : Dubai Health Insurance Corporation
ECC : Early Childhood Caries
GA : General Anaesthesia
HPSD : Health Policies and Standards Department
HRS : Health Regulation Sector
LA : Local Anaesthesia
MS : Mutans Streptococci
N2O : Nitrous Oxide
O2 : Oxygen
PADS : Post-Anesthesia Discharge Scoring System
PALS : Pediatric Advanced Life Support
PEARS : Pediatric Emergency Assessment, Recognition and Stabilization
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PHCSS : Primary Healthcare Services Sector
PPM : Parts per million
SaO2 : Oxygen saturation
SDF : Silver Diamine Fluoride
S-ECC : Severe Early Childhood Caries
UAE : United Arab Emirates
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A. GUIDELINES FOR APPLICATION OF FLUORIDE VARNISH
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1. BACKGROUND
Fluoride varnish is one of the best options for increasing the availability of topical
fluoride, regardless of the levels of fluoride in the water supply. Fluoride varnish is the
most effective additional fluoride agent for reducing caries in both the primary and
permanent dentition. High quality evidence of the caries-preventive effectiveness of
fluoride varnish in both permanent and primary dentitions has been reported in the
literature. A number of systematic reviews conclude that applications two or more
times a year produce a mean reduction in caries increment of 37% in the primary
dentition and 43% in the permanent. The evidence supports the view that varnish
application can also arrest existing lesions on the smooth surfaces of primary teeth
and roots of permanent teeth. Much of the evidence of effectiveness is derived from
studies, which have used sodium fluoride 22,600ppm varnish for application.
2. SCOPE
2.1. Provide recommendations to assist Pediatric dentist in the application of
Fluoride Varnish to the teeth of Pediatric patients.
3. PURPOSE
3.1. To equip health care provider with the necessary information and
recommendations for the application of fluoride varnish in pediatric patients.
3.2. To prevent and control dental caries in growing children.
4. APPLICABILITY
4.1. DHA licensed Pediatric dentists
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4.2. DHA licensed General Dentists.
5. RECOMMENDATION ONE: INDICATIONS
5.1. Indications according to age:
5.1.1. 0-2 years: Only for high caries risk patients, those who are likely to
develop caries and Special need patients, enhanced prevention is
required.
5.1.2. Two (2) years and above: For low caries risk, patient standard
prevention is required.
5.1.3. For High caries risk, patient enhanced prevention is required.
5.2. For all children aged two (2) years and over, apply fluoride varnish at least twice
per year.
5.3. Standard prevention for all children:
5.3.1. Apply sodium fluoride varnish (5%) twice a year.
5.3.2. Although a child might additionally receive fluoride varnish twice a year
from the preventive campaigns in the nursery or school, it is acceptable
for children to have varnish fluoride applied up to four times per year.
5.3.3. If residual varnish is visible or the child had varnish applied in the past
twenty–four (24) hours from preventive campaign in school, defer
application until next visit.
5.4. Enhanced prevention for children at increased risk of caries:
5.4.1. Apply sodium fluoride varnish four (4) times per year.
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5.4.2. The number of fluoride varnish applied in preventive campaigns should
be included in the total number of varnish application per year.
5.4.3. If recommending use of alcohol free sodium fluoride mouthwash for
children from seven (7) years of age in addition to fluoride varnish
application, advice that this should be used at a different time from
tooth brushing.
6. RECOMMENDATION TWO: ADVANTAGES
6.1. It is well accepted and considered to be safe.
6.2. The application of fluoride varnish is simple and requires minimal training.
6.3. While a thorough prophylaxis is not essential prior to application, removal of
gross plaque is advised.
7. RECOMMENDATION THREE: APPLICATION TECHNIQUE
7.1. Fluoride varnishes contain high concentration of fluoride and therefore it is
important to not exceed the manufacturer’s recommendations. Fluoride varnish
which contains 22600 ppm fluoride, 0.25 ml is used for children 2-5 years old
and 0.4 ml for children above five (5) years old.
7.2. As proximal surfaces of primary teeth are particularly prone to caries, it is
particularly important to include these areas when applying varnish to tooth
surfaces.
7.3. Teeth should be dried with cotton wool rolls or a triple syringe to optimize
adhesion of the varnish to the tooth.
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7.4. The varnish should be carefully applied with a micro brush to pits, fissures and
proximal surfaces of primary and permanent teeth and to any carious lesions.
7.5. The patient should be advised to avoid eating, drinking or rinsing for thirty (30)
minutes after application and wait at least four hours before brushing their
teeth or chewing hard food.
8. RECOMMENDATION FOUR: SPECIAL CONSIDERATIONS
8.1. The use of fluoride varnishes is contraindicated in patients with ulcerative
gingivitis and stomatitis.
8.2. There is a very small risk of allergy to colophony-containing fluoride varnishes.
A child who has been hospitalized due to severe asthma or allergy in the last
twelve (12) months or who is allergic to sticking plaster may be at increased
risk of an allergic reaction to colophony, so fluoride varnish application is
contraindicated. In these cases, consider using a colophony-free varnish or
suggest the use of alternative age appropriate fluoride preparations (e.g.
fluoride mouthwash or higher concentration fluoride toothpaste).
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B. GUIDELINES FOR APPLICATION OF SILVER DIAMINE FLUORIDE
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1. BACKGROUND
Dental caries affects about one out of four children aged 2-5 years. Silver Diamine
Fluoride (SDF) has shown to be efficacious in arresting caries lesions. It is a valuable
therapy which may be included as part of a caries management plan for patients.
Caries lesions treated with SDF usually turn black and hard. Stopping the caries
process in all targeted lesions may take several applications of SDF, and reapplication
may be necessary to sustain arrest.
Treatment of incipient caries usually involves early therapeutic intervention using
topical fluoride, and non-surgical restorative techniques such as dental sealants and
resin infiltration. The use and outcomes of these techniques have been well-
documented, and there are current policies and guidelines with recommendations for
their use in the practice of dentistry. In contrast, treatment of caries lesions
traditionally requires surgical intervention to remove diseased tooth structure
followed by placement of a restorative material to restore form and function. Barriers
to traditional restorative treatment (e.g., behavioural issues due to age and/or limited
cooperation, access to care, financial constraints) call for other alternative caries
management modalities.
SDF is thirty-eight percent SDF, which is equivalent to five percent fluoride in a
colourless liquid, with a pH of ten. The exact mechanism of SDF is not understood. It
is theorized that fluoride ions act mainly on the tooth structure, while silver ions, like
other heavy metals, are antimicrobial.
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It is also theorized that SDF reacts with hydroxyapatite in an alkaline environment to
form Calcium Fluoride (CaF2) and silver phosphate as major reaction products. CaF2
provides sufficient fluoride to form fluorapatite which is less soluble than
hydroxyapatite in an acidic environment. A side effect is the discoloration of
demineralized or cavitated surfaces. Patients and parents should be advised regarding
the black staining of the lesions associated with the application of SDF. Ideally, prior
to use of SDF, parents should be shown before- and after- images of teeth treated
with SDF.
The American Academy of Pediatric Dentistry (AAPD) recognizes that dental caries
continues to be a prevalent and severe disease in children. Therefore, the aim of this
guideline is to help practitioners (Pediatric dentist, General dentist) addresses the use
of SDF as part of an ongoing caries management plan with the aim of optimizing
individualized patient care consistent with the goals of a dental home.
2. SCOPE
2.1. The guideline intends to recommend the clinical practitioner involving the
application of SDF to enhance dental caries management outcomes in children
and adolescents, including people of determination.
3. PURPOSE
3.1. To help practitioners (Pediatrics dentist, General dentist) make decisions
involving the application of SDF to enhance dental caries management
outcomes in children and adolescents, including those with special health care
needs.
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3.2. To teach the clinician (Pediatric dentist, General dentist) how to administer
SDF in an effective, safe way.
3.3. To familiarizing the Pediatric dentist and General practitioner with the criteria
for tooth selection for SDF.
3.4. Standardize the management of Dental Caries Lesions with SDF.
4. APPLICABILITY
4.1. DHA licensed Pediatric dentists.
4.2. DHA licensed General Dental Practitioners.
5. RECOMMENDATION ONE: CLINICAL STEPS
5.1. Patients who may benefit from SDF include those:
5.1.1. With high caries risk who have active cavitated caries lesions in anterior
or posterior teeth.
5.1.2. Presenting with behavioural or medical management challenges and
cavitated caries lesions.
5.1.3. With multiple cavitated caries lesions that may not all be treated in one
visit.
5.1.4. With dental caries lesions that are difficult to treat.
5.1.5. Without access to or with difficulty accessing dental care.
5.1.6. In situations where aerosol generating procedures are avoided to
decrease risk of contagion during disease outbreak.
5.2. Criteria for tooth selection include:
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5.2.1. No clinical signs of pulpal inflammation or reports of
unsolicited/spontaneous pain.
5.2.2. Cavitated caries lesions that are not encroaching on the pulp. If
possible, radiographs should be taken to assess depth of caries lesions.
5.2.3. Cavitated caries lesions on any surface as long as they are accessible
with a brush for applying SDF. (Orthodontic separators may be used to
help gain access to proximal lesions).
5.2.4. SDF can be used prior to restoration placement and as part of caries
control therapy. Informed consent, particularly high- lighting expected
staining of treated lesions, potential staining of skin and clothes, and
need for reapplication for disease control, is recommended.
5.3. Clinical application of SDF
5.3.1. Remove gross debris from cavitation to allow better SDF contact with
denatured dentin.
5.3.2. Carious dentin excavation prior to SDF application is not necessary. As
excavation may reduce proportion of arrested caries lesions that
become black, it may be considered for aesthetic purposes.
5.3.3. A protective coating may be applied to the lips and skin to prevent a
temporary henna-appearing tattoo that can occur if soft tissues come
into contact with SDF.
5.3.4. Isolate areas to be treated with cotton rolls or other isolation methods.
If applying cocoa butter or any other product to protect surrounding
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gingival tissues, use care to not inadvertently coat the surfaces of the
caries lesions.
5.3.5. Caution should be taken when applying SDF on primary teeth adjacent
to permanent anterior teeth that may have non-cavitated (white spot)
lesions to avoid inadvertent staining.
5.3.6. Careful application with a micro-brush should be adequate to prevent
intraoral and extra oral soft tissue exposure. No more than one drop of
SDF should be used for the entire appointment.
5.3.7. Dry lesion with gentle flow of compressed air.
5.3.8. Bend micro sponge brush. Dip brush into SDF and dab on the side of
the plastic dappen dish to remove excess liquid before application.
Apply SDF directly to only the affected tooth surface. Remove excess
SDF with gauze, cotton roll, or cotton pellet to minimize systemic
absorption.
5.3.9. Application time should be at least one minute if possible. (Application
time likely will be shorter in very young and difficult to manage
patients. When using shorter application periods, monitor carefully at
post-op and re-care to evaluate arrest and consider re-application).
5.3.10. Apply gentle flow of compressed air until medicament is dry. Try to
keep isolated for as long as three minutes.
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5.3.11. The entire dentition may be treated after SDF treatment with five
percent sodium fluoride varnish to help prevent caries on the teeth and
sites not treated with SDF.
5.4. Follow-up
5.4.1. Estimations of SDF effectiveness in arresting dental caries lesions
range from 47 to 90 percent with one-time application depending on
size of the cavity and tooth location. Anterior teeth have higher rates
of arrest than posterior teeth. There- fore, follow-up for evaluation of
caries arrest is advisable.
5.4.2. Follow-up at 2-4 weeks after initial treatment to check the arrest of
the lesions treated.
5.4.3. Reapplication of SDF may be indicated if the treated lesions do not
appear arrested (dark and hard). Additional SDF can be applied at recall
appointments as needed, based on the colour and hardness of the
lesion or evidence of lesion progression.
5.4.4. Caries lesions can be restored after treatment with SDF.
5.4.5. When lesions are not restored after SDF therapy, bi-annual re-
application shows increased caries arrest rate versus a single
application.
6. RECOMMENDATION TWO: SPECIAL CONSIDERATIONS
6.1. Potential adverse effects:
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6.1.1. The main disadvantage of SDF is its aesthetic result (i.e., permanently
blackens enamel and dentinal caries lesions and creates a temporary
henna-appearing tattoo if allowed to come in contact with skin).
6.1.2. Skin pigmentation is temporary since the silver does not penetrate the
dermis.
6.1.3. Desquamation of the skin with pigmentation occurs when
keratinocytes are shed over a period of fourteen (14) days.
6.1.4. SDF also permanently stains most surfaces (e.g., counters, clothing)
with which it comes into contact.
6.1.5. No allergic reactions to SDF except if patient has allergy to silver
compounds, and might have pain if he had any oral ulcers (not
recommended to apply if patient has ulcers or gingival inflammation).
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C. GUIDELINES FOR THE APPLICATION OF HALL TECHNIQUE
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1. BACKGROUND
The Hall Technique is a method for managing carious or hypoplastic primary molars
where decay is sealed under Preformed Metal Crowns (PMCs) without local
anesthesia, tooth preparation or any caries removal.
The technique is named after Dr. Norna Hall, a general dental practitioner from
Scotland, who developed and used the technique for over 15 years until she retired in
2006. A retrospective analysis of the outcomes for the teeth she treated in this way
was published in the British Dental Journal in 2006. This showed the technique to
have outcomes comparable to conventional restorative techniques
Clinical trials have shown the Hall Technique to be effective, and acceptable to the
majority of children, their parents and clinicians. It is not, however, an easy, quick fix
solution to the problem of the carious primary molar. Like all clinical interventions, for
success the Hall Technique requires careful and appropriate case selection, a high level
of clinical skill, excellent patient management and long term monitoring. In addition, it
must always be provided with a full and effective caries preventive program.
The Hall Technique manipulates the plaque’s environment by sealing it into the tooth,
separating it from the substrates it would normally receive from the oral environment.
There is a possibility that the plaque may continue to receive some nutrition from
perfusion through the dentinal tubules.
However, there is good evidence that if caries is effectively sealed from the oral
environment, the bacterial profile in the caries changes significantly to a less
cariogenic community, and the lesion does not progress.
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Numerous studies have proven that the Hall technique outperforms the conventional
counterpart with regards to longevity and patient compliance. It was found that Hall
Technique was preferred to conventional restorations by the majority of the children,
their parents, and dentists.
2. SCOPE
2.1. For the effective management of carious or hypoplastic primary molars where
decay is sealed under preformed metal crowns (PMCs), without local
anesthesia, tooth preparation or any caries removal.
3. PURPOSE
3.1. To improve compliance in young children and reduce anxiety associated with
dental treatment (behavioural management technique).
3.2. To increase the use of SSCs by clinicians.
3.3. To avoid negative child health impacts and costs of repeat treatment.
3.4. To reduce tooth extraction and extensive treatment.
3.5. To be used in conjunction with a preventive program will reduce hospital
admissions for dental treatment under general anesthesia.
4. APPLICABILITY
4.1. DHA licensed Pediatric dentists.
4.2. DHA licensed General Dental Practitioners.
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5. RECOMMENDATION ONE: CASE SELECTION
5.1. With proper case selection, the Hall Technique can be an effective management
option for primary molar teeth affected by dental caries. A full history and
clinical examination, including bitewing radiography, should be carried out.
5.2. There should be a clear radiolucent band between the carious lesions and the
pulp of the tooth intended to be restored with the Hall Technique. There should
be no signs or symptoms of pulpal pathosis.
5.3. Indications include teeth with:
5.3.1. Proximal (Class II) lesions, cavitated or non-cavitated.
5.3.2. Occlusal (Class I) lesions, non-cavitated if the patient is unable to
accept a fissure sealant, or conventional restoration.
5.3.3. Occlusal (Class I) lesions, cavitated if the patient is unable to accept
partial caries removal technique, or a conventional restoration.
5.4. Contra indications for fitting Hall crowns include:
5.4.1. Signs or symptoms of irreversible pulpitis, or dental sepsis.
5.4.2. Clinical or radiographic signs of pulpal involvement, or periradicular
pathology.
5.4.3. Insufficient sound tissue left to retain the crown.
5.4.4. Patient co-operation where the clinician cannot be confident that the
crown can be fitted without endangering the patient’s airway.
5.4.5. A patient at risk from bacterial endocarditis.
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5.4.6. Parent or child unhappy with aesthetics. This should become apparent
though at the treatment planning stage when treatment options are
being discussed and agreed with the parent and child.
6. RECOMMENDATION TWO: STEPS FOR FITTING A HALL CROWN
6.1. Assessing the tooth shape, contact points/areas and the occlusion
6.1.1. Hall crowns can often be fitted successfully to primary molars that are
in contact with adjacent teeth, as there is some elasticity in the
periodontal ligament that can absorb the displacement necessary to fit
the crown. Some teeth have very broad contact points, which can make
fitting crowns difficult. In such cases, placing orthodontic separators
through the mesial and distal contacts can be useful when fitting
crowns with the Hall Technique. The patient seen 3 to 5 days later for
removal of the separator and fitting of the crown.
6.1.2. Sometimes there would be difficulty in placement of crown due to
crown morphology or marginal breakdown and tooth movement. There
are several different approaches to manage this problem if a crown
cannot be fitted in the usual way:
a. Placement of a temporary restoration to rebuild the marginal ridge
and allow a separator to be placed to make space for the crown to
be fitted.
b. Adjusting the crown with band forming pliers.
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c. Trying a different crown: Use of a mandibular molar crown to fit a
maxillary first primary molar with significant loss of mesiodistal
width.
d. Carrying out some tooth preparation.
6.2. Protecting the airway
6.3. Sizing a crown
6.3.1. Select different sizes of crowns to find one that covers all the cusps,
and approaches the contact points, with a slight feeling of “spring
back”. Aim to fit the smallest size of crown that will seat.
6.3.2. Be particularly careful not to fit an oversize crown to a second primary
molar where the first permanent molar has still to erupt; this could
increase the risk of first molar impaction later.
6.3.3. Do not be tempted to fully seat the crown through the contact points
before cementation as they could be difficult to remove.
6.4. Loading the crown with cement
6.5. Fitting the crown, and first stage seating
6.6. Wipe the excess cement away, check fit, and second stage seating
6.7. Final clearance of cement, check occlusion (adjusting crown if necessary) and
discharge.
7. RECOMMENDATION THREE: SPECIAL CONSIDERATIONS
7.1. Hall crowns should not be fitted to opposing (occluding) teeth during the same
appointment. The occlusion should have re-established, with bilateral contacts,
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before opposing crowns are fitted. However, if a primary molar on either side
of the same arch needs a Hall crown (or diagonally opposite teeth in different
arches, i.e. a maxillary left primary molar and a mandibular right primary molar),
then these can (and ideally should) be fitted during the same appointment, as
the patient will have two crowns fitted with just one episode of bite propping.
7.2. Crowns will try to follow the path of least resistance, and so may tilt towards
the “easier” of the contacts, making it almost impossible then to ease the crown
through the tight contact. Concentrate on seating the crown through the tight
contact. The easy one should take care of itself.
7.3. If the crown does not seat sufficiently, then remove it using the excavator
before the cement sets. If the cement has set, a high-speed hand piece can be
used to section the crown through the buccal and occlusal surface, following
which it can easily be peeled off.
7.4. Patients and parents should be reassured that the child would be used to the
feeling within Twenty four (24) hours. Analgesia is usually not required. The
occlusion tends to adjust to give even contact on both sides within weeks.
7.5. If fitting crowns to second primary molars, particularly in the maxilla, before the
first permanent molars are erupted, keep an eye for the first permanent molars
becoming impacted against the crown margin as they erupt. This can occur even
if crowns have not been fitted. Nevertheless, if it does occur, it can often be
managed with orthodontic separators if detected early.
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7.6. If a primary molar fitted with Hall crown requires a pulp therapy, then this can
be carried out through the crown without needing to remove it.
7.7. Patients should be reviewed on a normal recall schedule, with radiographic
examination in line with current recommendations, and the Hall Technique
should be used in conjunction with a full preventive programme.
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D. GUIDELINES FOR THE USE OF LOCAL ANESTHESIA IN PEDIATRIC
PATIENTS
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1. BACKGROUND
Dental Local anaesthesia is the temporary loss of sensation including pain in one part
of the body produced by a topically applied or injected agent without depressing the
level of consciousness. Local anaesthetics act within the neural fibres to inhibit the
ionic influx of sodium for neuron impulse. This helps to prevent transmission of pain
sensation during procedures, which can serve to build trust and foster the relationship
of the patient and dentist, allay fear and anxiety, and promote a positive dental
attitude. The technique of local anaesthetic administration is an important
consideration in pediatric patient behaviour guidance. Age-appropriate
nonthreatening terminology, distraction, topical anaesthetics and proper injection
technique can help the patient have a positive experience during administration of
local anaesthesia.
In Pediatric dentistry, the dental professional should be aware of proper dosage
(based on weight) to minimize the chance of toxicity and the prolonged duration of
anaesthesia, which can lead to accidental lip, tongue, or soft tissue trauma.
Therefore, the aim of this guideline is to help practitioners (Pediatric dentist, General
dentist) make decisions when using local anaesthesia to control pain in infants,
children, adolescents, and individuals with special health care needs during the delivery
of oral healthcare.
2. SCOPE
2.1. The scope of this guideline aims at familiarizing the Pediatric dentist and
general practitioner with most effective and safe techniques for administration
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of local anaesthesia in the Pediatric dental patient. Therefore, it is important
that dentists make every effort to minimize pain and discomfort during dental
treatment.
3. PURPOSE
3.1. To help practitioners (Pediatric dentist, General dentist) make decisions when
using local anaesthesia to control pain in infants, children, adolescents, and
individuals with special health care needs during the delivery of oral health care.
3.2. To ensure safe, atraumatic, and effective administration of local anaesthesia
injection to a child.
4. APPLICABILITY
4.1. DHA licensed Pediatric dentists.
4.2. DHA licensed General Dental Practitioner.
5. RECOMMENDATION ONE: TOPICAL ANESTHETICS
5.1. The application of a topical anaesthetic may help minimize discomfort caused
during administration of local anaesthesia. Topical anaesthetic is effective on
surface tissues (up to two to three mm in depth) to reduce painful needle
penetration of the oral mucosa. Topical anaesthetic agents are available in gel,
liquid, ointment, patch, and aerosol forms.
5.2. Topical anesthetic may be used prior to the injection of a Local Anesthetic (LA)
to reduce discomfort associated with needle penetration.
5.3. The pharmacological properties of the topical agent should be understood.
5.4. A metered spray is recommended if an aerosol preparation is selected.
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5.5. Systemic absorption of the drugs in topical anesthetics must be considered
when calculating the total amount of anesthetic administered.
6. RECOMMENDATION TWO: SELECTION OF SYRINGES AND NEEDLES
6.1. The American Dental Association (ADA) has long-standing standards for
aspirating syringes for use in the administration of local anesthesia. Needle
selection should allow for profound local anesthesia and adequate aspiration.
6.2. These recommendations may include:
6.2.1. For the administration of local dental anesthesia, dentists should select
aspirating syringes that meet ADA standards.
6.2.2. Short needles may be used for any injection in which the thickness of
soft tissue is less than 20 millimetres. A long needle may be used for a
deeper injection into soft tissue. Any 23- through 30- gauge needle
may be used for intraoral injections, since blood can be aspirated
through all of them. Aspiration can be more difficult, however, when
smaller gauge needles are used. An extra-short, 30-gauge is
appropriate for certain infiltration injections.
6.2.3. Needles should not be bent if they are to be inserted into soft tissue
to a depth of greater than five millimeters or inserted to their hub
for injections to avoid needle breakage.
7. RECOMMENDATION THREE: INJECTABLE LOCAL ANESTHETIC (LA) AGENTS
7.1. Local amide anesthetics available for dental usage include lidocaine,
mepivacaine, articaine, prilocaine, and bupivacaine. Absolute contraindications
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for LA include a documented LA allergy. True allergy to an amide is exceedingly
rare.
7.2. For patients having an allergy to bisulfates, use of a LA without a
vasoconstrictor is indicated. LA without vasoconstrictors should be used with
caution due to rapid systemic absorption, which may result in overdose.
7.3. A long-acting LA (i.e., bupivacaine) is not recommended for the child or the
physically or mentally disabled patient due to its prolonged effect, which
increases the risk of soft tissue injury.
7.4. Selection of LA agents should be based upon:
7.4.1. The patient’s medical history and mental/developmental status.
7.4.2. The anticipated duration of the dental procedure.
7.4.3. The need for haemorrhage control.
7.4.4. The planned administration of other agents (e.g., nitrous oxide,
sedative agents, general anaesthesia).
7.4.5. The practitioner’s knowledge of the aesthetic agent.
7.5. Use of vasoconstrictors in LA is recommended to decrease the risk of toxicity
of the anesthetic agent, especially when treatment extends to two or more
quadrants in a single visit.
7.6. In cases of bisulphate allergy, use of a LA without a vasoconstrictor is indicated.
A LA without a vasoconstrictor also can be used for shorter treatment needs
but should be used with caution to minimize the risk of toxicity of the anesthetic
agents.
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7.7. The established maximum dosage for any anesthetic should not be exceeded.
7.8. Administration of LA should be based on the weight/body mass index (BMI) of
the patient.
8. RECOMMENDATION FOUR: DOCUMENTATION OF LOCAL ANESTHESIA
8.1. The patient record is an essential component of the delivery of competent and
quality oral health care. Appropriate documentation includes specific
information relative to the administration of local anesthesia.
8.2. These recommendations may include:
8.2.1. Documentation must include the type and dosage of LA. Dosage of
vasoconstrictors, if any, must be noted.
8.2.2. Documentation may include the type of injection(s) given (e.g.,
infiltration, block, intraosseous), needle selection, and patient’s
reaction to the injection.
8.2.3. In patients for whom the maximum dosage of LA may be a concern, the
weight should be documented preoperatively.
8.2.4. If the LA was administered in conjunction with sedative drugs, the
doses of all agents must be noted on a time-based record.
8.2.5. Documentation should include that post-injection instructions were
reviewed with the patient and parent.
9. RECOMMENDATION FIVE: LA COMPLICATIONS
9.1. Toxicity (overdose):
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9.1.1. Most adverse drug reactions develop either during the injection or
within five to 10 minutes. Overdose of LA can result from high blood
levels caused by a single inadvertent intravascular injection or repeated
injections.
9.1.2. LA toxicity can be prevented by careful injection technique, watchful
observation of the patient, and knowledge of the maximum dosage
based on weight. Practitioners should aspirate before every injection
and inject slowly.
9.2. Allergy to local anaesthesia:
9.2.1. Allergic reactions are not dose related but are due to the patient’s
heightened capacity to react to even a small dose. Allergies can
manifest in a variety of ways, some of which include urticaria,
dermatitis, angioedema, fever, photosensitivity, or anaphylaxis.
Anesthetic toxicity can be prevented by careful injection technique,
watchful observation of the patient, and knowledge of the maximum
dosage based on weight. Practitioners should aspirate before every
injection and inject slowly.
9.3. Paraesthesia:
9.3.1. Paraesthesia is persistent anesthesia beyond the expected duration.
Trauma to the nerve can result in paresthesia and, among other
etiologies; the needle can cause trauma during the injection.
9.4. Postoperative soft tissue injury:
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9.4.1. Self-induced soft tissue trauma is an unfortunate clinical
complication of LA use in the oral cavity. Most lip and cheek-biting
lesions of this nature are self-limiting and heal without
complications, although bleeding and infection are possible.
9.4.2. Caregivers responsible for postoperative supervision should be
given a realistic time for duration of numbness and informed of the
possibility of soft tissue trauma.
9.5. Recommendations to reduce local anaesthetic complications:
9.5.1. Practitioners who utilize any type of local anaesthetic in a Pediatric
dental patient should have appropriate training, skills, and have
available the proper facilities, personnel, and equipment to manage any
reasonably foreseeable emergency.
9.5.2. Care should be taken to ensure proper needle placement during the
intraoral administration of LAs. Practitioners should aspirate before
every injection and inject slowly.
9.5.3. Residual soft tissue anesthesia should be minimized in pediatric and
special health care needs patients to decrease risk of self-inflicted
postoperative injuries.
9.5.4. Following an injection, the doctor, hygienist, or assistant should remain
with the patient while the anesthetic begins to take effect.
9.5.5. Practitioners should advise patients and their caregivers regarding
behavioural precautions (e.g., do not bite or suck on lip/cheek, do not
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ingest hot substances) and the possibility of soft tissue trauma while
anesthesia persists. Placing a cotton roll in the mucobuccal fold may
help prevent injury and lubricating the lips with petroleum jelly helps
prevent drying. Practitioners who use pheytolamine mesylate
injections to reduce the duration of local anesthesia still should
follow these recommendations.
10. RECOMMENDATION SIX: LOCAL ANASTHESIA WITH SEDATION, GENERAL
ANASTHESIA, AND/OR NITROUS OXIDE/OXYGEN ANALGESIA/ANXIOLYSIS
10.1. Particular attention should be paid to local anaesthetic doses used in children
.To avoid excessive doses for the patient who is going to be sedated, a maximum
recommended dose based upon weight should be calculated .
10.2. The dosage of local anaesthetic need not be altered if nitrous oxide/oxygen
analgesia/anxiolysis administered.
10.3. When general anaesthesia is employed, local anaesthesia may be used to reduce
the maintenance dosage of the anaesthetic drugs. The anaesthesiologists
should be informed of the type and dosage of the local anaesthetic used.
Recovery room personnel also should be informed.
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E. GUIDELINES FOR NITROUS OXIDE (N2O) INHALATION SEDATION
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1. BACKGROUND
All children should expect pain free, high quality dental care, which can be achieved
with sedation for some children that exhibit behavior challenges. When sedation is
used there is an additional, separate need for pain control in form of local anesthesia
and behavior management.
Pain and anxiety management is of paramount importance in dentistry. As many as
10-30% of adults and children may have some form of fear or anxiety related to
dental treatment. There is substantial evidence that these patients will benefit from
sedation with Nitrous oxide (N2O) and that this form of sedation is extremely safe
and efficient in the trained dental practitioner’s hands.
N2O conscious sedation is defined as diminution or elimination of pain and anxiety in
a conscious patient. The patient responds normally to verbal commands. All vital signs
are stable, there is no significant risk of losing protective reflexes, and the patient is
able to return to pre-procedure mobility. N2O is a colourless and virtually odourless
gas with a faint, sweet smell. It is an effective analgesic/anxiolytics agent causing
Central Nervous System (CNS) depression and euphoria with little effect on the
respiratory system. N2O is absorbed rapidly, allowing for both rapid onset and
recovery (2-3 minutes). It causes minimal impairment of any reflexes, thus protecting
the cough reflex. Although rare, silent regurgitation and subsequent aspiration need
to be considered with N2O/Oxygen (O2) sedation.
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2. SCOPE
2.1. For the effective and successful conscious sedation with N2O of pediatric
patients in clinical practice.
3. PURPOSE
3.1. To reduce or eliminate anxiety.
3.2. To minimize psychological trauma related to early dental treatment.
3.3. To enhance communication and patient cooperation.
3.4. To increase tolerance for longer appointments.
3.5. To reduce gagging.
3.6. To reduce costs related to repeat treatment.
4. APPLICABILITY
4.1. DHA licensed Pediatric dentists.
5. RECOMMENDATION ONE: SEDATION IN PEDIATRIC DENTISTRY
5.1. In contrast to adult sedation, in children the procedure has the objective of
controlling behaviour and achieving complete treatment in a safe and efficient
way.
5.2. The child’s cooperation and the Pediatric Dentist’s behaviour guidance may vary
according to the child’s age.
6. RECOMMENDATION TWO: TRAINING FOR N2O SEDATION
6.1. The pediatric dentist shall be granted Clinical Privilege to provide N2O sedation
by the Clinical Privileging Committee (CPC) or Medical Director of the health
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facility aligned with his/her training credentials and qualifications, training,
competence, practical independence and experience.
6.2. A health facility should apply to HRS to provide clinical training for N2O
sedation and should fulfil all criteria mentioned in the Guidelines for Clinical
Training Facilities on the DHA website.
6.3. Training of pediatric dentists in N2O sedation should include theoretical
training as well as practical training.
6.4. Training and experience should be regularly updated and maintained.
6.5. The clinical privileged pediatric dentists should:
6.5.1. Have current Pediatric Advanced Life Support (PALS)/Pediatric
Emergency Assessment, Recognition and Stabilization (PEARS).
6.5.2. Have an ability to rescue patient whose level of sedation becomes
deeper than initially intended.
6.5.3. Have the knowledge for the management of complications due to
conscious sedation.
6.6. Dental auxiliary personnel assisting during conscious sedation sessions shall
also have appropriate but shorter training and theory and practical training in
basic life support.
7. RECOMMENDATION THREE: PATIENT SELECTION
7.1. The selection of the patient is based on a careful clinical examination and a well-
documented medical and dental history elaborated by the Pediatric Dentist.
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7.2. Determination of risk factors and a better understanding of the patient’s profile
are mandatory.
7.3. If a single risk factor is found, an anaesthesiologist must be consulted in order
to decide whether the patient can be submitted to the sedative procedure.
Patients must be classified according to the American Society of
Anesthesiologists (ASA) classifying system as shown in Table 1 below.
Table 1 - American society of anesthesiologists (ASA) physical status
classification evaluation
ASA Classification
Class I No organic, physiological, biochemical or psychiatric alterations
Class II Moderate systemic alterations (diabetes, asthma)
Class III Severe systemic alterations (acute diabetes, psychomotor
retardation, severe pulmonary failure)
Class IV Severe alterations that may endanger life (heart failure)
Class V Moribund patient with no chances of surviving a surgery
7.4. Sedation with N2O can be performed in ASA III and ASA IV patients, provided
its use is restricted to hospitals and under the supervision of a responsible
anaesthesiologist.
Note: Refer to the clinical pathway decision making process of N2O
administration in Appendix 1.
8. RECOMMENDATION FOUR: INDICATIONS
8.1. The most common indications are discussed:
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8.1.1. Patients showing low to moderate apprehensive behaviour, capable of
understanding and following simple instructions.
8.1.2. Patients aged four or over, although there is support for a minimum
age of six or eight, depending on how well the child cooperates with the
basic behaviour techniques.
8.1.3. Patients with a severe vomiting reflex that makes the dental treatment
otherwise impossible.
8.1.4. Special patients who present physical or mental disorders.
8.1.5. Patients who require more sitting time because of complex or multiple
treatments.
8.1.6. Invasive medical diagnoses and minor surgeries.
8.1.7. A fearful, anxious patient.
8.1.8. A patient whose gag reflex interferes with dental care.
8.1.9. ASA Class I patients (Table 1).
9. RECOMMENDATION FIVE: CONTRAINDICATION
9.1. Non-cooperative patients who exhibit a highly anxious and apprehensive
profile.
9.2. Hysterical, stubborn or defiant patients who refuse the mask due to age,
maturity, behaviour or personality disorder.
9.3. Psychotic or drug addicted patients, due to the influence of severe emotional
disorder.
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9.4. Patients with upper respiratory tract infection, Chronic Obstructive Pulmonary
Disease (COPD), acute otitis, sinusitis or a recent (less than two weeks) ear,
nose or throat operation, under chemotherapy with bleomycin4 or with
porphyria.
9.5. Some COPD.
9.6. ASA II, III, IV, V.
10. RECOMMENDATION SIX: PATIENT ASSESSMENT
10.1. The dentist must conduct a thorough patient assessment to cover the
following, but not limited to:
10.1.1. Medical History including prescribed medication,
10.1.2. Dental History,
10.1.3. Assessment of anxiety level,
10.1.4. Previous conscious sedations and general anesthesia,
10.1.5. Indication for the use of conscious sedation,
10.1.6. Pre-sedation assessment,
10.1.7. Drug allergies.
11. RECOMMENDATION SEVEN: PATIENT INFORMATION
11.1. The pediatric dentist must document, but not limited to the following:
11.1.1. Parents/Guardian's nitrous oxide sedation informed consent,
11.1.2. Pre-procedure assessment record,
11.1.3. Monitoring record,
11.1.4. Post procedure record.
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11.2. Pre-operative Instruction
11.2.1. Fasting is not required for patients undergoing N2O
analgesia/anxiolytics. The practitioner, however, may recommend that
only a light meal be consumed in the two (2) hours prior to the
administration of N2O.
11.3. Post-operative Information
11.3.1. The patient shall be accompanied to and from the treatment facility by
a parent, legal guardian, or other responsible person. It is preferable to
have two (2) or more adults accompany children who are still in car
safety seats if transportation to and from a treatment facility is
provided by one (1) of the adults.
11.4. Restraint
11.4.1. If immobilization devices are used, such as papoose boards, it must be
applied in such a way as to avoid airway obstruction or chest restriction.
11.4.2. If an immobilization device is used, a hand or foot should be kept
exposed, and the child should never be left unattended.
11.4.3. Oral or written consent is required for use of any type of restraint.
11.5. Patient monitoring
11.5.1. A dentist, or at the dentist’s direction, an appropriately trained
individual, must remain in the treatment room during active dental
treatment, to monitor the pediatric patient continuously until the
patient meets the criteria for discharge.
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11.5.2. The appropriately trained individual must be familiar with monitoring
techniques and equipment.
11.5.3. Monitoring must include:
a. Oxygenation
I. Colour of mucosa, skin or blood must be evaluated continually.
II. O2 saturation by pulse oximetry may be clinically useful and
should be considered.
b. Ventilation
I. The dentist and/or appropriately trained individual must
observe chest excursions continually.
c. Circulation
I. Heart rate should be evaluated pre-operatively, intra-
operatively and postoperatively.
II. Blood pressure readings can be obtained pre and post
operatively.
d. Discharge Criteria
I. The qualified dentist or appropriately trained clinical staff
must monitor the patient during recovery until the patient is
ready for discharge by the dentist.
II. The qualified dentist must determine and document that level
of consciousness; oxygenation, ventilation and circulation are
satisfactory prior to discharge.
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III. The instruction must be given written and verbal to the
patient, parent, escort, guardian or care giver on the following:
Appropriate diet,
Medications,
Management of possible postoperative bleeding,
Level of activity,
Pre and Post-operative,
Post-sedation assessment and time of discharge home
Table 2 is a sedation scale that can be used to monitor the
effect of the sedation.
Table 2- Sedation scale according to Wilton (8)
Agitated Clinging to parent and/or crying
Alert Awake but not clinging to parent, may whimper but not cry
Calm Sitting or lying comfortable with eyes spontaneous open
Drowsy Sitting or lying comfortable with eyes spontaneous closing but
responds to minor stimulation
Asleep Eyes closed, rousable but does not respond to minor stimulation
a. Documentation and records- It is recommended that the
documentation include the following:
I. N2O Sedation informed consent,
II. Patient education form about sedation, pre and post
operatively instruction,
III. Pre-assessment record,
IV. Intra-operative record,
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V. Recovery record,
VI. Patient response to N2O,
VII. The course of the treatment,
Monitoring
Dose, and route of administration of sedative drugs
Dental treatment performed
Sedation evaluation (sedation scale)
Accept of sedation and treatment (behavioural scale)
Complications
VIII. Discharge record.
12. RECOMMENDATION EIGHT: TECHNIQUES OF N2O/O2 SEDATION
12.1. Perform time-out.
12.2. Selection of an appropriately sized nasal hood.
12.3. A flow rate of 5 to 6 L/min.
12.4. Introduction of 100% O2 for 1 to 2 minutes followed by titration of N2O in 10%
intervals.
12.5. The concentration of N2O should not routinely exceed 50% at any point of time.
12.6. During treatment, it is important to continue the visual monitoring and
documenting of the patient’s vital signs, respiratory rate and level of
consciousness.
12.7. Once the N2O flow is terminated, 100% O2 should be delivered for 3 to 5 minute
to avoid diffusion hypoxia.
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12.8. Discontinue if nausea, light-headedness or other side effects occur.
12.9. The patient must meet the discharge criteria and return to pre-treatment
responsiveness before discharge.
13. RECOMMENDATION NINE: PATIENT MONITORING
13.1. During the procedure Sp02/Pulse/Nitrous oxide-Oxygen Percentage/Sedation
Score must be monitored.
13.2. After the procedure the Sp02/Pulse/Temperature/BPI/Sedation Score must
be monitored.
14. RECOMMENDATION TEN: ADVERSE EFFECTS OF N2O INHALATION
14.1. Nausea and vomiting are the most common adverse effects.
14.2. A higher incidence with longer administration of nitrous oxide, fluctuations in
N2O levels, and increased concentrations of N2O.
15. RECOMMENDATION ELEVEN: DISCHARGE CRITERIA
15.1. Patient must meet the discharge criteria and vital signs return to pre-procedure
readings.
15.2. Post-operative verbal and written instructions must be given to the patient,
parent, escort, guardian or caregiver.
15.3. Modified discharge criteria Post Anesthesia Discharge Scoring System (PADS)
for determining home readiness of the patient must be completed and patients
are ready to discharge home if the total score > 11.
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Modified discharge criteria (PADS)
Breathing Able to breathe deeply
and coughing
2 Circulation BP is ±20% of the
pre-procedural initial
value
2
Dyspnoea or shortness
of Breath
1 BP is ±20% to 50%
of the pre-procedural
initial value
1
Apnoea 0 BP is >±50% of the
pre-procedural initial
value
0
Level of
conscious
ness
Fully conscious 2 O2
Saturation
Able to maintain SaO2
> 92% on Room air
2
Responding to verbal
command
1 Needs O2 therapy to
maintain SaO2 >92%
1
Not responding 0 SaO2 <92% even with
O2 therapy
0
Nausea &
Vomiting
No or minimal 2 Pain No or minimal 2
Moderate 1 Moderate 1
Severe 0 Severe 0
16. RECOMMENDATION TWELVE: SAFETY OF STAFF
16.1. Chronic exposure to trace concentrations of N2O has been reported to
constitute an occupational health hazard. Consequently, the dental staff must
follow strict indications for the use of nitrous oxide, only use N2O delivery
systems with an efficient scavenging system, have appropriate technique for
disconnection of the delivery system, and have methods for testing the integrity
of the breathing system.
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17. RECOMMENDATION THIRTEEN: EQUIPMENT
17.1. The various equipment required in N2O administration are enlisted below:
17.1.1. Appropriately fitting nasal hood.
17.1.2. Fail-safe Mechanism that is checked and calibrated regularly and
documented
17.1.3. Inhalation equipment must have the capacity for delivering 100%, and
never less than 30%, O2 concentration at a flow rate appropriate to
the child’s size.
17.1.4. If N2O/ O2 delivery equipment capable of delivering more than 70%
N2O and less than 30% O2 is used, an inline O2 analyser must be used.
17.1.5. Equipment should be current, accurate and include a scavenging
system.
17.1.6. Emergency cart must be able to accommodate children of all ages and
sizes. It should include equipment to resuscitate a non-breathing,
unconscious patient and provide continuous support until trained
emergency personnel arrive.
17.1.7. A positive pressure oxygen delivery system capable of administering
>90% O2 at a 10 L/min flow for at least 60 minutes (650 L, “E”
cylinder) must be available.
17.1.8. Documentation of emergency equipment and drugs regularly on
scheduled basis.
17.1.9. Inspect pressure connections for absence of leaks.
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17.1.10. Inspect the conducting tubing and reservoir bag to the unit if not
already in place.
17.1.11. Connect the conducting tubing and reservoir bag to the unit if not
already in place.
17.1.12. Make sure to have replacement equipment and cylinders on hand.
17.1.13. Ensure the cylinder colour should be different from other cylinder such
as oxygen and Liquid Petroleum Gas (LPG). Oxygen Cylinder should be
black and Nitrous oxide Cylinder should be Blue.
17.1.14. Infection control.
a. The equipment used for inhalation sedation must be prevented
from causing cross infections. During use, various parts of the
equipment will be contaminated to some extent.
b. The nasal hood/masks are in direct contact with the patient’s skin
around the nose and upper lip, which will be carrying a variety of
microorganisms. Therefore, it is recommended to use a single use,
disposable nasal hoods/mask or which can be autoclave.
c. The scavenger breathing system and reservoir bags should be
sterilized/disinfected as per the manufacturer’s instruction.
d. Disinfect re-usable equipment such as connecting tubes after each
patient use.
e. Any part of the tubing that is not corrugated can be sterilized but
is not necessary. Surface disinfection is adequate.
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17.1.15. Storage of equipment.
a. Nitrous oxide equipment must be stored in a secure, locked space.
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F. GUIDELINES FOR COMPLETE ORAL REHABILITATION UNDER
GENERAL ANAESTHESIA
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1. BACKGROUND
Pediatric dentists seek to provide oral healthcare to infants, children, adolescents and
persons with special healthcare needs in a manner that promotes excellence in quality
of care and concurrently induces a positive attitude in the patient toward dental
treatment. Behavior guidance techniques have allowed most pediatric dental patients
to receive treatment in the dental office with minimal discomfort and without
expressed fear. Minimal or moderate sedation has allowed others who are less
compliant to receive treatment. Some children and individuals with special care needs
who have extensive oral healthcare needs, acute situational anxiety, uncooperative
behavior, immature cognitive functioning, disabilities, or medical conditions require
deep sedation/General Anesthesia (GA) to receive dental treatment in a safe and
humane fashion.
GA is a clinician-controlled state of patient unconsciousness accompanied by a loss of
protective reflexes, including the ability to maintain an airway independently and
respond purposefully to physical stimulation or verbal command. The use of GA
sometimes is necessary to provide quality dental care for the child.
The Dubai Health Authority recognizes that using non-pharmacological behavior
guidance techniques in certain patients may sometimes present a challenge for the
pediatric dentist in the dental clinic; hence, GA is required to undergo comprehensive
dental procedures safely in those patients.
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2. SCOPE
2.1. Establish a clear recommendations and protocol to be practiced by all Pediatric
Dentists in order to provide quality dental care that is standardized, successful
and efficient when referring to and performing complete oral rehabilitation
under GA in children.
3. PURPOSE
3.1. To reduce or eliminate anxiety.
3.2. To minimize psychological trauma related to early dental treatment.
3.3. To increase tolerance for longer appointments.
3.4. To reduce gagging.
3.5. To reduce costs related to repeat treatment.
4. APPLICABILITY
4.1. DHA licensed Pediatric dentists.
5. RECOMMENDATION ONE: BENEFITS COMPLETE ORAL REHABILITATION
UNDER GA
5.1. Improvement in the quality of life by treatment of extensive dental disease in
children who are experiencing pain and difficulties in eating and sleeping.
5.2. Facilitating quality dental care for medically compromised patients with special
health care needs.
5.3. Allowing the treatment of anxious, defiant and fearful children who exhibit
uncooperative behaviour on the dental chair thus protecting their developing
psyche.
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6. RECOMMENDATION TWO: PATIENT SELECTION CRITERIA
6.1. When considering the use of GA, the following general considerations need to
be taken into account:
6.1.1. Children who cannot cooperate due to lack of psychological or
emotional maturity and/or mental, physical, or other medical disability.
6.1.2. The extremely uncooperative, fearful, anxious, or uncommunicative
child or adolescent.
6.1.3. Patients for whom local anesthesia is ineffective because of acute
infection, anatomic variations, or allergy.
6.1.4. Patients requiring immediate, comprehensive oral/dental care.
6.1.5. Patients requiring significant surgical procedures.
6.1.6. Patients for whom the use of GA may protect the developing psyche
and/or reduce medical risk.
7. RECOMMENDATION THREE: PATIENT EXCLUSION CRITERIA
7.1. Patients less than three (3) years old that require short dental treatment or
asymptomatic cases where treatment can be delayed until child is older or more
cooperative.
8. RECOMMENDATION FOUR: PRE-OPERATIVE ASSESSMENT (PROTOCOL OF
REFERRAL)
8.1. The pediatric dentist must first assess the child and confirm if they meet the
criteria for complete oral rehabilitation under GA.
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8.2. A provisional treatment plan must be formulated and discussed with the
parents after clinical evaluation and/or radiographic examination (if possible
and age appropriate).
8.3. The referring pediatric dentist must rule out the following:
8.3.1. If the child is medically compromised a medical fitness letter from the
concerned physician must be obtained before referral for complete oral
rehabilitation under GA. The referring pediatric dentist should
communicate any special instructions from the child’s physician
regarding the treatment under GA in the patient’s health record.
8.3.2. Involvement of the first permanent molars; an appropriate consultation
must be done with oral surgery, an endodontist or orthodontist before
referral for GA.
8.3.3. If any teeth require root canal therapy, the prognosis and restorability
of the involved teeth must be confirmed with the endodontist. Such
cases must be planned in advance before scheduling the patient for GA.
8.3.4. If any permanent molars require extraction, an orthodontist must be
consulted to confirm the treatment plan. A consultation with an oral
surgeon must be done in case of any anticipated complicated
extractions otherwise simple extraction of permanent first molars can
be performed by the pediatric dentist.
9. RECOMMENDATION FIVE: PRE-OPERATIVE INVESTIGATIONS
9.1. Prior to undergoing GA, all patients must have the following investigations:
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9.1.1. Blood investigations Full Blood Count,
9.1.2. Hepatitis B Surface Antigen,
9.1.3. HIV Antigen and Antibody,
9.1.4. Referral to Pre-anesthesia clinic,
9.1.5. All the necessary information such as admission protocol, importance
of having anesthesia check-up appointment prior to GA day, failure to
attend the anesthesia check-up appointment and cancellation of GA
must be explained to the patient’s parent/guardian.
10. RECOMMENDATION SIX: TREATMENT UNDER GA
10.1. Operating doctor must confirm the final or provisional treatment plan with the
parent on the day of operation. Parents must be specifically informed about
treatment with metal crowns, extractions of permanent teeth or extraction of
primary anterior teeth with or without temporary prosthetic replacement.
10.1.1. Restorations:
a. Any small occlusal lesions can be restored using composite or
compomer restorative material if the lesion is confined to the
occlusal surface only. Any deep fissures on molars can be sealed
with flowable composite material.
b. Class II restorations in primary molars should NOT be performed
under GA.
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c. Multi-surface carious lesions in primary molars should be restored
with stainless steel crowns and using strip crowns for anterior
teeth.
d. Extensive carious lesions and/or enamel defects in permanent first
molars must be restored with stainless steel crowns.
e. A root canal treated permanent first molar must be restored with
stainless steel crown.
f. Glass Ionomer material should not be used as final restorative
material unless justified.
10.1.2. Root Canal Therapy:
a. Standard root canal therapy of primary molars must be followed,
which includes performing the pulpotomy and filling using IRM
temporary filling followed by stainless steel crown.
b. Root canal therapy (pulpotomy/pulpectomy) should not performed
on primary teeth with history of abscess, facial cellulitis and root
resorption of more than 1/3 of the tooth.
c. Root canal treated permanent molars and permanent anterior
teeth require full coverage using stainless steel crowns for molars
and composite strip/celluloid crowns for anterior teeth.
10.1.3. Extractions:
a. All non-restorable teeth should be extracted under GA.
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b. Balanced extraction of anterior teeth especially canines must be
considered.
c. Sutures are advised after all extractions. A hemostatic agent such
as surgicel can be used in combination with sutures in cases of
persistent bleeding and/or children with coagulation disorders.
10.1.4. Space Maintainers:
a. Space maintainer impressions could be taken during or after
complete oral rehabilitation under GA especially before the
eruption of first permanent molars and in very young children.
10.1.5. Duration of Procedure:
a. Duration of routine procedure should not exceed ninety (90)
minutes. However, in case the procedure extended beyond that,
then the reason should be justified.
11. RECOMMENDATION SEVEN: DISCHARGE AND POST-OPERATIVE CARE
11.1. The responsibility of discharging the patient post-operatively is shared between
the dentist, the anaesthesiologist and the nursing staff.
11.2. The discharge policies of the hospital are to be followed in addition to the
following:
11.2.1. The patient’s parents should receive verbal and written post-operative
instructions especially if extractions or any surgical procedure has been
performed.
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11.2.2. Advice should be given about any symptoms that might be experienced
by the patient in the first twenty four (24) hours following discharge.
11.2.3. Analgesics such as paracetamol or Ibuprofen are recommended and
should be prescribed to the patient for use in the first twenty four (24)
to forty eight (48) hours post-operatively.
11.2.4. Oral hygiene instructions should be reemphasized and oral care post-
operatively should be explained clearly.
11.2.5. The patient should be scheduled for post- operative follow up with the
operating pediatric dentist to ensure healing and the status of any
absorbable (dissolving) sutures in addition to taking impressions for
space maintainers if indicated.
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G. GUIDELINES FOR MANAGEMENT OF EARLY CHILDHOOD CARIES
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1. BACKGROUND
Oral health is an essential part of overall health and thus Pediatricians have a
responsibility to include oral health as a part of their overall assessment of children.
Providing oral healthcare requires a specific level of knowledge to facilitate
communication, referral, collaboration and ongoing follow-up and care.
Dental caries in preschool children or Early Childhood Caries (ECC) is a chronic,
transmissible infectious disease affecting the primary (milk) teeth. Dental caries among
children is reported to occur between 5 to 8 times more frequently than asthma. It can
result in considerable suffering, pain, reduction of quality of life of affected children
and disfigurement and can frequently compromise their future dentition.
The etiology of the condition is a combination of:
Frequent consumption of fermentable carbohydrates as liquids, especially at night,
usually as a result of on-demand breast- or bottle-feeding,
Oral colonization by cariogenic bacteria (especially Gram Positive Mutans
Streptococci) and
Poor oral hygiene.
The prevalence of ECC worldwide has been reported to vary between 3% and 94%. In
the United Arab Emirates (UAE), ECC is by far the most common childhood disease
and its prevalence of ECC has been reported as 93.8% in 5 year old children.
Primary Physicians and Pediatricians are in a unique position to ensure that patients
and other caregivers receive information on the prevention of oral disease in infants
and young children. By working together, Pediatricians and family physicians can
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complement each other’s efforts to provide comprehensive preventive oral care to their
population. Moreover, they must have adequate knowledge of the disease process, its
etiology, risk factors, clinical presentation, prevention and intervention strategies.
Therefore, this guideline aims to provide an up-to-date information on terminology,
etiology, prevalence, clinical picture and preventive strategies of early childhood caries.
2. SCOPE
2.1. To provide an overview on early childhood caries and timely referral of pediatric
patients for appropriate oral treatment.
3. PURPOSE
3.1. To increase knowledge of oral disease prevention from infancy through
adolescence.
3.2. To improve the quality of oral health in pediatric patients.
3.3. To reduce costs related to repeat treatment.
4. APPLICABILITY
4.1. DHA licensed Pediatric dentists.
4.2. DHA licensed General Dental Practitioners.
5. RECOMMENDATION ONE: ETIOLOGY OF EARLY CHILDHOOD CARIES (ECC)
5.1. Dental caries is a common chronic infectious transmissible disease resulting
from tooth- adherent specific bacteria, primarily Mutans Streptococci (MS)
that metabolize sugars to produce acid which, over time, demineralizes tooth
structure.
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5.2. MS generally is considered to be the principal group of bacterial organisms
responsible for the initiation of dental caries.
5.3. MS colonization of an infant may occur from the time of birth. Significant
colonization occurs after dental eruption as teeth provide non-shedding
surfaces for adherence. Other surfaces also may harbor MS, For example, the
furrows of the tongue.
5.4. Vertical transmission of MS from mother to infant is well documented. The
higher the levels of maternal salivary MS, the greater the risk of the infant being
colonized. Along with salivary levels of MS, mother’s oral hygiene, periodontal
disease, snack frequency, and socioeconomic status also are associated with
infant colonization.
5.5. Reports indicate that horizontal transmission (i.e., between members of a group
such as siblings of a similar age or children in a day-care center) may also be of
concern.
5.6. The child’s cooperation and the Pediatric Dentist’s behaviour guidance may vary
according to the child’s age.
6. RECOMMENDATION TWO: CLINICAL REPRESENTATION OF EARLY CHILDHOOD
CARIES
6.1. In most cases of ECC, the first clinical sign is a band of dull white
demineralization along the gingival line of the maxillary incisor teeth.
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6.2. As the lesion progresses, the white bands develop into brown or black cavities
around the necks of the incisors. In severe cases, the crowns of the teeth are
amputated leaving only root stumps.
6.3. The most commonly affected teeth are the maxillary incisors. The mandibular
incisors are usually not affected because the teat of the bottle is usually held
above the tongue during sucking, so the lower incisors are protected by the
tongue and also by the flow of saliva from the submandibular ducts.
6.4. The commonly involved surfaces are the labial, palatal, mesial, distal of maxillary
incisors and of the maxillary and mandibular canines. In the first and second
primary molars, the occlusal surface is commonly affected.
7. RECOMMENDATION THREE: CONSEQUENCES OF ECC
7.1. Caries in primary teeth can affect children’s growth, cause significant tooth pain
and potentially life threatening infections, all of which can and diminish overall
quality of life.
7.2. Untreated ECC lesions may cause abscess, cellulitis and spread of infection,
which may result in serious and fatal complications such as brain abscess and
Ludwig’s angina.
7.3. Management of ECC complications requires increased emergency room visits
and hospitalization. The socio-economic consequences of ECC manifest in
increased treatment costs and missing school time as well as time off from
employment for parents.
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8. RECOMMENDATION FOUR: MANAGEMENT OF ECC
8.1. Dental caries is a disease that generally is preventable. Early risk assessment
allows for identification of parent-infant groups who are at risk for ECC and
would benefit from early preventive intervention. The ultimate goal of early
assessment is the timely delivery of educational information to populations at
high risk for developing caries in order to prevent the need for later surgical
intervention.
9. RECOMMENDATION FIVE: CARIES RISK ASSESSMENT
9.1. The most common indications are discussed.
9.2. Caries risk assessment is the determination of the likelihood of the incidence of
caries (i.e. the number of new cavitated or incipient lesions) during a certain
time period or the likelihood that there will be a change in the size or activity of
lesions already present.
9.3. With the ability to detect caries in its earliest stages (i.e. white spot lesions),
healthcare providers can help prevent cavitation.
9.4. Caries risk assessment models currently involve a combination of factors
including diet, fluoride exposure, a susceptible host, and microflora that
interplay with a variety of social, cultural, and behavioural factors.
9.5. Risk assessment tools can aid in the identification of reliable predictors and
allow dental practitioners, physicians, and other non-dental health care
providers to become more actively involved in identifying and referring high-
risk children. Appendix 2 incorporate available evidence into practical tools to
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assist general physicians, and pediatricians to in assessing levels of risk for
caries development in infants, children, and adolescents.
9.6. Circling those conditions that apply to a specific patient helps the health care
worker and parent understand the factors that contribute to or protect from
caries. Risk assessment categorization of low or high is based on
preponderance of factors for the individual. However, clinical judgment may
justify the use of one factor (e.g. frequent exposure to sugar containing snacks
or beverages, visible cavities) in determining overall risk. The Overall
assessment of the child’s dental caries risk is checked below as High or Low.
10. RECOMMENDATION SIX: PERINATAL PERIOD AND ANTICIPATORY GUIDANCE
10.1. The perinatal period is defined as the period around the time of birth, beginning
with the completion of the 20th to 28th week of gestation and ending one to
four weeks after birth. The perinatal period plays a crucial role for the well-
being of pregnant women.
10.2. Identifying mothers with high levels of dental caries and poor oral health and
educating them on the importance of their own oral health and the future
health of their unborn child can help change their trajectory of oral health.
Timely delivery of educational information and preventive therapies to these
parents may reduce the incidence of ECC, prevent the need for dental
rehabilitation, and improve the oral health of their children. Physicians, nurses,
and other health care professionals are far more likely to see expectant or new
mothers and their infants than are dentists. Therefore, it is essential that these
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providers be aware of oral anomalies and associated risk factors of dental caries
in order to make appropriate decisions regarding timely and effective
interventions for pregnant women and facilitate the establishment of a dental
home for the child.
10.3. Anticipatory guidance is the process of providing practical, developmentally
appropriate information about children’s health to prepare parents for the
significant physical, emotional and psychological milestones.
10.4. Anticipatory guidance to reduce the risk of dental caries should include:
10.4.1. Counselling regarding brushing of child’s teeth twice daily with the
appropriate amount of fluoridated toothpaste.
10.4.2. Diet analysis.
10.4.3. Counselling to reduce the consumption of sugar containing beverages.
11. RECOMMENDATION SEVEN: RECOMMENDATIONS FOR PERINATAL AND
INFANT ORAL HEALTH
11.1. Oral Health Care of pregnant and lactating.
11.1.1. Diet Counselling:
a. Adequate quality and quantity of nutrients for the mother-to-be
and the unborn child. Information regarding the caries process and
food cravings that may increase the mother’s caries risk.
b. Cariogenicity of certain foods and beverages, role of frequency of
consumption of these substances, and the
demineralization/remineralisation process.
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c. Continued breast-feeding along with complementary foods for a
period of one year or longer. The transfer of drugs and therapeutics
into breastmilk should be considered, especially in infants younger
than six months of age.
11.1.2. Comprehensive oral examination:
a. Referral to dental clinic for a comprehensive oral examination and
treatment during pregnancy.
11.1.3. Professional oral health care:
a. Routine professional dental care for the parent can help optimize
oral health. Removal of active caries, with subsequent restoration
of remaining tooth structure, in the parents suppresses the MS
reservoir and minimizes the transfer of MS to the infant, thereby
decreasing the infant’s risk of developing ECC.
11.1.4. Oral hygiene:
a. Brushing with fluoridated toothpaste and flossing by the parent are
important to help dislodge food and reduce bacterial plaque levels.
11.1.5. Fluoride:
a. Using a fluoridated toothpaste and rinsing with an alcohol-free,
over-the-counter mouth rinse containing 0.05 percent sodium
fluoride once a day or 0.02 percent sodium fluoride rinse twice a
day have been suggested to help reduce plaque levels and promote
enamel remineralisation.
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11.1.6. Xylitol chewing gum:
a. Evidence suggests that the use of xylitol chewing gum (at least two
to three times a day by the mother) has a significant impact on
mother-child transmission of MS and decreasing the child’s caries
rate.
11.2. Oral healthcare for the infant/children.
11.2.1. Oral health risk assessment:
a. Every infant should receive an oral health risk assessment from
his/her primary health care provider or qualified health care
professional by six (6) months of age.
11.2.2. Establishment of a dental home:
a. Establishment of a dental home begins no later than twelve (12)
months of age and includes referral to dental specialists when
appropriate.
11.2.3. Teething:
a. Teething can lead to intermittent localized discomfort in the area
of erupting primary teeth, irritability, and excessive salivation;
however, many children have no apparent difficulties. Treatment of
symptoms includes oral analgesics and chilled rings for the child to
gum.
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b. Use of topical anesthetics, including over-the-counter teething
gels, to relieve discomfort are discouraged due to potential toxicity
of these products in infants.
11.2.4. Oral hygiene:
a. Oral hygiene measures should be implemented no later than the
time of eruption of the first primary tooth. Tooth-brushing should
be performed for children by a parent twice daily, using a soft
toothbrush of age-appropriate size and the correct amount of
fluoridated toothpaste.
11.2.5. Diet:
a. Human breast milk is uniquely superior in providing the best
possible nutrition to infants and has not been epidemiologically
associated with caries. However frequent night time bottle feeding
with milk and ad libitum breast-feeding are associated with, but not
consistently implicated in, ECC. Breastfeeding greater than seven
times daily after twelve (12) months of age is associated with
increased risk for ECC. Night time bottle feeding with juice,
repeated use of a sippy or no-spill cup, and frequent in between
meal consumption of sugar-containing snacks or drinks (e.g., juice,
formula, soda) increase the risk of caries. The American Academy
of Pediatrics has recommended children one through six years of
age consume no more than four to six ounces of fruit juice per day,
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from a cup (i.e., not a bottle or covered cup) and as part of a meal
or snack.
11.2.6. Fluoride:
a. The use of fluoride for the prevention and control of caries is
documented to be both safe and effective. The correct amount of
fluoridated toothpaste should be used twice daily. No more than a
smear or rice-sized amount of fluoridate toothpaste should be used
for children under age three; no more than a pea-sized amount
should be used for children ages three to six.
11.2.7. Injury prevention:
a. Practitioners should provide age-appropriate injury prevention
counselling for orofacial trauma. Initially, discussions would include
play objects, pacifiers, car seats, and electric cords.
11.2.8. Non-nutritive habits:
a. Non-nutritive oral habits (e.g., digit or pacifier sucking, bruxism,
abnormal tongue thrust) may apply forces to teeth and
dentoalveolar structures. It is important to discuss the need for
early sucking and the need to wean infants from these habits before
the age of three (3) years old.
12. RECOMMENDATION EIGHT: CONCLUSION
12.1. Oral health is an integral part of the overall health and well-being of children. A
Pediatrician who is familiar with the science of dental caries, capable of
Guidelines for Pediatric Dentistry Page 80 of 96 Ref. No. HRS/HPSD/PED/V1/2021
assessing caries risk, comfortable with applying various strategies of
prevention and intervention and connected to dental resources can contribute
considerably to the health of his/her patients.
12.2. Pediatricians see children from a young age and on a more frequent basis than
general or pediatric dentists and therefore, they are in a perfect position to
evaluate the risk of dental decay, start prevention and refer children who need
dental treatment. However, there are several barriers to educating pediatricians
and medical practitioners including issues related to professional boundaries
between dentistry and medicine and time limitations.
12.3. Incorporating children’s oral health into DHA medical residency programs and
through continued medical education courses and better, open communication
between medical and dental professional can minimize these barriers.
12.4. Pediatric dental oral health program is accepted to be included in DHA medical
residency curriculum. This guideline is the core reference for building the
curriculum for medical residents in DHA with pre and post-assessment of
knowledge which has commenced in 2018.
Guidelines for Pediatric Dentistry Page 81 of 96 Ref. No. HRS/HPSD/PED/V1/2021
KEY PERFORMANCE INDICATORS (KPIs)
1. Patient Happiness: Overall Assessment
DHA Pillar Patient Happiness
Indicator
Name
Overall Assessment
Measure Type Outcome
Data Source Survey data
Measure
Description
People who had a very favorable overall assessment of the facility during
measurement period
Measure
Denominator
All survey respondents who meet inclusion criteria
Measure
Numerator
Survey respondent whose overall assessment of the facility was very high
- patients with the highest possible score (scale has 2-7 options) or the
two highest options (scale has 8+ options)
Measure
Inclusion
Criteria
Total number of valid responses to surveys that ask a patient to give their
overall assessment of a facility
Measure
Exclusion
Criteria
None
Source DHA
International
Benchmark
None: Dubai facility surveys are not sufficiently uniform to allow
benchmarking
Higher is
Better
Yes
Risk Adjust
This Measure
No
Guidelines for Pediatric Dentistry Page 82 of 96 Ref. No. HRS/HPSD/PED/V1/2021
2. Patient Happiness: Recommendation to Others
DHA Pillar Patient Happiness
Indicator
Name
Recommendation to Others
Measure Type Outcome
Data Source Survey data
Measure
Description
Percentage of patients who were very likely to recommend the facility to
other people during measurement period
Measure
Denominator
All survey respondents who meet inclusion criteria
Measure
Numerator
Survey respondent whose recommendation was very high - patients with
the highest possible score (scale has 2-7 options) or the two highest
options (scale has 8+ options)
Measure
Inclusion
Criteria
Total number of valid responses to surveys that ask whether the patient
would recommend the facility to others
Measure
Exclusion
Criteria
None
Source DHA
International
Benchmark
None: Dubai facility surveys are not sufficiently uniform to allow
benchmarking
Higher is
Better
Yes
Risk Adjust
This Measure
No
Guidelines for Pediatric Dentistry Page 83 of 96 Ref. No. HRS/HPSD/PED/V1/2021
3. Patient Happiness: Doctors Made Sure Patient Understood All Information
DHA Pillar Patient Happiness
Indicator Name Doctors Made Sure Patient Understood All Information
Measure Type Outcome
Data Source Survey data
Measure
Description
Percentage of patients who answered favorably ('yes') that doctors made
sure he/she understood all information
Measure
Denominator
All survey respondents who met inclusion criteria
Measure
Numerator
Survey respondent indicated 'yes,' doctors made sure that the patient
understood all information
Measure
Inclusion
Criteria
Valid response to the survey question ('yes' or 'no')
Measure
Exclusion
Criteria
None
Source DHA
International
Benchmark
None: Dubai facility surveys are not sufficiently uniform to allow
benchmarking
Higher is
Better
Yes
Risk Adjust
This Measure
No
Guidelines for Pediatric Dentistry Page 84 of 96 Ref. No. HRS/HPSD/PED/V1/2021
4. Patient Safety: Rate of Medication Error
DHA Pillar Patient Safety
Indicator Name Rate of Medication Error
Measure Type Outcome
Data Source Internal facility records, reports, or survey data
Measure
Description
Rate of prescriptions per 100,000 with a dispensing error during
measurement period
Measure
Denominator
Number of medication prescriptions during measurement period
Measure
Numerator
Number of prescriptions in which a medication error occurs (e.g.
dispensing error, prescribing error, administering and preparing error,
patient compliance error, vaccine error, administering a medicine for a
known allergy patient, dose-related adverse drug reaction)
Measure
Inclusion Criteria
All filled prescriptions
Measure
Exclusion
Criteria
Unsafe condition and near miss incident, adverse drug reactions
Source TEC required measures
http://apps.who.int/iris/bitstream/10665/252274/1/9789241511643-eng.pdf
International
Benchmark
2.28 Per 100,000 (in the U.S.)
Source: https://www.nationwidechildrens.org/newsroom/news-
releases/2017/07/study-finds-rate-of-medication-errors-resulting-in-
serious-medical-outcomes-rising .
One medication error occurs for every five doses given in US hospitals
and 1-2% of patients admitted to US hospitals are harmed by
medication errors. Source: http://stateclaims.ie/wp-
content/uploads/2017/11/Medication-Incidents-Report-2016.pdf
Higher is Better No
Risk Adjust This
Measure
No
Guidelines for Pediatric Dentistry Page 85 of 96 Ref. No. HRS/HPSD/PED/V1/2021
5. Patient Safety: Rate of Medical Error
DHA Pillar Patient Safety
Indicator Name Rate of Medical Error
Measure Type Outcome
Data Source Internal facility records, reports, or survey data
Measure
Description
Rate of medical errors (errors in diagnosis, medication, surgery, equipment
use, lab findings interpretation) per 100,000 patients in measurement
period
Measure
Denominator
All qualifying patients in measurement period
Measure
Numerator
Medical errors as defined through proven reports (e-medical systems)
during measurement period
Measure
Inclusion
Criteria
All patients with at least one medical encounter in measurement year
Measure
Exclusion
Criteria
None
Source TEC required measures
http://apps.who.int/iris/bitstream/10665/252274/1/9789241511643-eng.pdf
International
Benchmark
To be discussed with DHA
Higher is
Better
No
Risk Adjust
This Measure
No
Guidelines for Pediatric Dentistry Page 86 of 96 Ref. No. HRS/HPSD/PED/V1/2021
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APPENDICES:
APPENDIX 1: CLINICAL PATHWAY IN THE DECISION MAKING PROCESS FOR THE USE
OF N2O ADMINISTRATION
Does the patient have fear/anxiety of dental
procedures?
Does the patient have a gag reflux preventing
him/her from cooperating during the procedure?
Does the patient have any of the following?
Chronic Obstructive Pulmonary Disease
B12 Deficiency?
Administration
Ensure time out is done for N2O
Turn on N2O machine. Turn on Scavenging system
Introduce 100% oxygen for 1-2 minutes
Ask the patient to take slow deep breaths of 100%oxygen
from his nose for 1-2 minutes, and then introduce N2O in
increments of 5% making sure not to exceed 50%. Avoid
unnecessary conversation to limit exhalation of N2O in the
room
Continue the visual monitoring of patients respiratory rate
and level of consciousness
Document the vital signs, percentage of N2O and sedation
score throughout the procedure
At the end of the dental procedure, discontinue N2O and
provide 100% oxygen for 3-5 minutes
Patient must meet the discharge criteria and vital signs
should return to pre procedure readings.
No
No
Use N2O for behavioral management
Obtain an Informed Consent from Parent/guardian,
Provide Educational Material,
Explain fasting protocol
Check the equipment and monitoring devices, Select
appropriate nasal mask, Perform Time-out, Ensure
emergency cart is available
Use alternative ways of behavior
management techniques Yes
Yes
Use alternative ways of behavior
management techniques
Guidelines for Pediatric Dentistry Page 96 of 96 Ref. No. HRS/HPSD/PED/V1/2021
APPENDIX 2: CARIES- RISK ASSESSMENT FORM FOR 0-3 YEARS OLDS
Caries- risk Assessment Form for 0-3 Years Olds for Physicians and Other Non-Dental
Professionals
Factors High Risk Low Risk
Biological
Mother/primary caregiver has active cavities
Parent/caregiver has low socioeconomic status
Child has >3 between meal sugar-containing snacks or beverages per day
Child is put to bed with a bottle containing natural or added sugar
Child has special health care needs
Child is a recent immigrant
Yes
Yes
Yes
Yes
Yes
Yes
Protective
Child receives optimally-fluoridated drinking water or fluoride supplements
Child has teeth brushed daily with fluoridated toothpaste
Child receives topical fluoride from health professional
Child has dental home/regular dental care
Yes
Yes
Yes
Yes
Clinical Findings
Child has white spot lesions or enamel defects
Child has visible cavities or fillings
Child has plaque on teeth
Yes
Yes
Yes
Overall assessment of the child’s dental caries risk: High ☐ Low ☐
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